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NUR: 718 > Mental/Psych Disorders > Flashcards

Mental/Psych Disorders Flashcards

1
Q

Anxiety - key characteristics

A
  • subjective sense of dread or unease
  • most common psychiatric disorder
  • comorbidities = depression
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2
Q

Anxiety - exam findings

A
  • first step is to determine if anxiety comes before or after a medical illness or it is because of a med side effect
  • evaluate for physical explanation
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3
Q

Anxiety - management

A
  • Buspar (serotonin-receptor antagonist) - for patients with already established dx of anxiety, good for chronic/long-term therapy
  • Benzos - very effective short-term, caution in elderly
  • refer to psychiatry
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4
Q

Generalized Anxiety Disorder (GAD) - clinical presentation

A
  • many potential presentations
  • restless, irritability, difficulty concentrating, muscle tension, sleep disturbances, insomnia, fatigue, SOB, tachycardia, diarrhea, headache
  • do thorough H&P: can cause somatic complaints, can be caused by meds
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5
Q

Generalized Anxiety Disorder (GAD) - diagnostics

A
  • to rule out medical illness

- CBC, BMP, TSH, urine, EKG

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6
Q

Generalized Anxiety Disorder (GAD) - screening tools

A
  • GAD-7: 7 questions about mental state over the past week. > 10 = moderate anxiety
  • GAD-2
  • suicide risk assessment
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7
Q

Generalized Anxiety Disorder (GAD) - diagnostic criteria

A
  • *excessive anxiety and worry, occurring more days than not for at least 6 months
  • anxiety/worry associated with 3 of the following: restlessness/ on-edge feeling, easily fatigued, difficulty concentrating, going blank, irritability, muscle tension, sleep disturbances
  • not d/t direct effects of substance or general medical condition
  • anxiety and symptoms cause significant distress in important areas of functioning
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8
Q

Generalized Anxiety Disorder (GAD) - non-pharm management

A
  • education: avoid stimulants and etoh
  • cognitive behavioral therapy
  • most effective combo is cognitive behavioral therapy + pharm tx
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9
Q

Generalized Anxiety Disorder (GAD) - pharm management

A
  • *SSRIs (first line), 4-6 weeks for effect, side effects early in tx (headaches, decreased libido), do not stop abruptly, ex: paroxetine (Paxil) and sertraline (Zoloft)
  • SNRIs: venlafaxine (Effexor) CAN CAUSE INCREASED BP
  • benzos: okay for short-term, may be used with SSRIs/SNRIs until they take effect
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10
Q

Generalized Anxiety Disorder (GAD) - follow-up/referral

A
  • follow up: every 1-2 weeks when adjusting dose, some are on meds indefinitely
  • refer to psych when provider feels they don’t have a good handle on patient
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11
Q

Panic Disorder - definition

A
  • presence of recurrent, unpredictable panic attacks, which are distinct episodes of intense fear or discomfort associated with physical symptoms
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12
Q

Panic Disorder - diagnostic criteria

A
  • one month of concern or worry about the attacks or change in behavior r/t them
  • attacks have sudden onset (within 10 minutes) and are usually resolving over the course of an hour and occur in unexpected fashion
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13
Q

Panic Disorder - treatment

A
  • goal: decrease frequency of attacks and reduce intensity
  • antidepressants: SSRIs (Paxil, sertraline (Zoloft), Celexa, Lexapro
  • SSRIs take a while to have effect so may need short-term benzo
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14
Q

Depression - types

A
  • major depressive disorder (MDD): biggest risk factor is personal hx of depression
  • dysthymic disorder: when patient has depressive symptoms for 2 years, worse in winter
  • Bipolar disorders: typically worse in fall
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15
Q

Depression - who is more likely to be depressed?

A
  • *previous episode of depression
  • elderly
  • female
  • concurrent medical illness or substance abuse
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16
Q

Depression - when to suspect?

A
  • Pain: headaches, chronic complaints of pain
  • unexplained GI complaints
  • low energy, chronic fatigue
  • apathy, irritability, anxiety
  • sexual complaints
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17
Q

Depression - physical findings

A
  • poor hygiene, unkempt appearance
  • weight gain
  • significant constipation or impaction, GI complaints
  • slowed body systems
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18
Q

Depression - in men

A
  • thought of as “female disorder”
  • more likely to talk about physical symptoms (tired, low performance/sexual desire)
  • less likely to show sadness, irritability
  • 4x more likely to commit suicide
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19
Q

Depression - screening tools

A
  • 2-item screening tool:
    1. in the past month have you felt down, depressed, or hopeless?
    2. in the past month have you felt little interest or pleasure in doing things?
  • PHQ-9: questionnaire that helps determine if pt has mild, moderate, or severe depression
  • Beck Depression Inventory
  • Geriatric Depression Scale
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20
Q

Depression - management (non-pharm)

A
  • psychotherapy + meds = best combo
  • always rule out suicidal ideation (huge risk factor for suicide is previous attempt)
  • treat underlying condition first and refer to psych if uncomfortable or too extensive
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21
Q

Depression - management (pharm)

A 
SSRIs
-citalopram (Celexa), paroxetine (Paxil), fluoextine (Prozac), sertraline (Zoloft)
- *major side effects: headaches (usually initial but will usually fade), sexual dysfunction, serotonin syndrome 
SNRIs
- venlafaxine (Effexor)
- do not give with MAOIs
- *watch BP!
- usually tried when SSRIs fail 
TCAs
- amitriptyline (Elavil)
- more side effects
- lethal in overdose 
- need cardiac monitoring
MAOIs
- tranylcypromine (Parnate)
- dietary restriction (Tyramine)
- risk of hypertensive crisis after intake of tyramine
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22
Q

Depression - follow-up

A
  • 1 week: suicide risk increases (energy level increase)
  • 2 weeks
  • monthly
  • prescription duration: 6-12 months after remission, longer if multiple disorders or longer hx of depression
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23
Q

Depression - referral

A
  • suicidal or homicidal behavior

- failing therapy after 1-2 months

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24
Q

Major Depression - criteria

A

KNOW THIS

  • occurrence of one major and five or more minor symptoms for 2 weeks
  • major: depressed mood or loss of interest or pleasure
  • minor: depressed mood most of day, significant weight loss/gain, psychomotor agitation, insomnia, or hypersomnia
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25
Q

Major Depression - most common presenting symptom

A
  • adhedonia (don’t have ability to feel pleasure)
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26
Q

Major Depression - treatment

A
  • psychotherapy + SSRIs

- ECT, TMS, and ketamine infusions are also other less common options

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27
Q

Suicide - characteristics

A
  • 10th leading cause of death in US
  • men > women, older white, and live alone
  • *70% of suicides see PCP within 6 weeks of suicide
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28
Q

Suicide - clinical features

A
  • *hopelessness (reg flag)
  • may or may not state intentions to you
  • may start to give away possessions, quit job
  • *may appear abruptly peaceful (red flag)
  • self-mutilation, making threats, hallucinations/ delusions
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29
Q

Suicide - assessment

A
  • always assess for suicidal ideation, intent, and plan
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30
Q

Suicide - risk acronym

SAD PERSONAS

A 
S - sex
A - age
D - depressions
P - previous attempts
E - ethanol abuse
R - rational thinking loss
S - social support loss
O - organized plan
N - no spouse
A - availability of lethal means
S - sickness
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31
Q

Bipolar - characteristics

A
  • episodic shifting between mania and major depression, hypomania, and mixed mood states
  • prevention of mood cycling is crucial
  • mood fluctuations are chronic and must be present for 2 years before dx can be made
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32
Q

Bipolar - treatment

A

KNOW THIS

  • Lithium (mainstay)
  • side effects: GI issues, n/v, polyuria, weight gain, skin eruptions, edema
  • need to be checking BMP for GFR and kidney function and lithium levels
  • sustained lithium of at least 0.8 is optimal prophylaxis
  • also need to be treating their depression (antidepressants)
  • refer to psych if needed
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33
Q

Schizophrenia - characteristics

A
  • group of syndromes characterized by “massive disruption” in thinking, mood, and behavior, poor filtering of stimuli
  • often has insidious onset in late adolescence and often has poor outcome (progresses from social withdrawal, perceptual distortion, to recurrent delusions and hallucinations)
  • multifactorial causes
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34
Q

Schizophrenia - criterira

A
  • positive and negative symptoms for a 1 month period and continued signs for at least 6 months to make dx
  • *positive: hallucinations, delusions, formal thought disorder
  • *negative: decreased social ability, restricted affect, poverty of speech, anhedonia, decreased emotional expression, impaired concentration, diminished social engagement
  • negative symptoms influence poor outcomes and poor response to tx
  • dx of exclusion
35
Q

Schizophrenia - diagnostics

A

CT/MRI is necessary for 1st episode of any schizophrenia or psychotic episode of unknown cause (rule out brain lesion/tumor)

36
Q

Schizophrenia - treatment

A
  • Antipsychotic meds
  • mainstay
  • good at treating positive symptoms
  • “Atypicals”: clozapine (can cause agranulocytosis and seizures, WBC count weekly, seizure precautions), risperidone
  • “Typicals”: phenothiazines, thioxanthnese, haldol
  • full remission takes 6-8 weeks, works in 70% of patients
  • side effects: QT PROLONGATION, weight gain, extrapyramidal symptoms, neuroleptic malignant syndrome, tardive dyskinesia
37
Q

Violence in Acute Care Setting - differentials

A
  • aggression and violence usually symptoms and not a disease
  • aggression: depression, schizophrenia, personality disorders, mania, paranoia
  • impulse control disorders: physical abuse, pathological intoxication
38
Q

Violence in Acute Care Setting - warning signs

A
  • if abuser has hx of violence, it is the best predictor they will do it again
  • provocative behavior
  • angry demeanor
  • loud, aggressive speech
  • tense posture
  • frequently changing body position/pacing
39
Q

Domestic Violence - symptomatology

A
  • trouble expressing anger
  • long-term anger
  • passivity in relationships
  • feels “marked for life”
  • feels “deserving” of abuse
  • lack of trust
  • dissociation of affect
40
Q

Domestic Violence - red flag

A

If abuser has controlling behaviors toward the abused, wants to be in exam room and won’t leave, or patient has unexplained or inconsistent injuries

41
Q

Domestic Violence - managing victim

A
  • treat as a trauma victim
  • assist pt in finding therapeutic relationship
  • temporary emergency centers/counseling
  • treat medical/psych problems
  • be compassionate
  • look for scars, bite marks, poorly healed fractures, bruises (esp. on inner aspect of bony), vaginal or anal laceration/wounds, may have significant tachycardia or anxiety (esp. if abuser is around)
  • Xray, SANE exam, STI exam, etc.
42
Q

Grief - stages

A

Denial, anger, bargaining, depression, acceptance

43
Q

Grief - uncomplicated grief

A
  • natural human response
  • emotional, physical, behavioral, cognitive, spiritual, social aspects
  • should be diminished within a 6-18 month time frame
44
Q

Grief - complicated grief characteristics

A
  • earliest complicated grief should be diagnosed 6 months post-loss and persists > 1 month
  • diagnosed if pt cannot carry out ADLs after 3 months
  • substantial distress, functional impairment, increased risk for suicide
45
Q

Grief - who is at risk for altered grief

A
  • PTSD, MDD are often comorbid
  • sudden death
  • prior experience with loss, chronic stress r/t medical condition, lack of support
46
Q

Grief - physical findings

A
  • extreme emotional pain
  • depression
  • physical pain
  • anger, loss of control
  • may have preoccupation with item/person they lost
  • may have suicidal or homicidal thoughts
  • depends on stage
47
Q

Grief - how to manage in acute care?

A
  • evaluate, keep them safe, talk, assess behaviors
  • psych referral, psychotherapy
  • SSRIs and TCAs are not appropriate for immediate grief
48
Q

Transgender - role as provider

A
  • always ask what name and pronoun they prefer
  • always keep in mind they are still at risk for certain risk factors for their biologic gender
  • when no private rooms available, room them according to preferred gender
49
Q

Transgender - med reconciliation

A

Testosterone - side effects include elevated BP, polycythemia, worsening lipid panel and glucose
Estrogens and anti-androgens - high risk of thrombosis (SMOKING = HUGE RISK FACTOR), elevation of BP and prolactin, migraines

50
Q

Powerlessness - role as provider

A
  • incorporate a “patient review” (similar to ROS) to address non-technical aspects of care - basically a “checking-in” with the patient to evaluate their concerns and if they are being addressed
  • ask for feedback, incorporate patient’s perceptions and suggestions into care
51
Q

Serotonin Syndrome - what is it?

A
  • serotonin toxicity
  • potentially life threatening
  • associated with increased serotonergic activity in CNS (hyper-stimulation/brainstorm of serotonin receptors)
  • SSRIs are biggest culprit - even larger risk if they are on multiple SSRIs and/or SNRIs
  • most present within 24 hours of addition of new serotonin med, most within 6 hours
52
Q

Serotonin Syndrome - diagnostics

A
  • dx made on clinical grounds

- labs to rule in/out differentials and monitor complications

53
Q

Serotonin Syndrome - Hunter Toxicity Criteria Decision Rule

A

Patient must have taken a serotonin agent and have a respective symptoms/criteria

54
Q

Serotonin Syndrome - symptomatology

A
  • myoclonus
  • agitation, anxiety
  • delirium
  • abdominal cramping
  • sweating
  • hyperpyrexia (high fevers)
  • HTN
  • vomiting
  • potentially death
55
Q

Serotonin Syndrome - mangement

A
  • depends on how severe your patient is
  • discontinue all serotonergic agents!
  • supportive tx: antipyretics, cooling blanket, etc.
  • sedation if necessary, intubation if necessary
  • serotonin antagonist (Cyproheptadine) if necessary
  • consult medical toxicologist, pharmacy, or poison control
  • usually lasts about 24 hours and will usually come back to baseline
56
Q

Tardive Dyskinesia - what is it?

A
  • serious side effect that may occur with use of certain meds used to treat mental illness
  • may appear as repetitive, jerking movements that occur in face, neck, and tongue
  • long-term use of meds (TCAs) can cause TD (25% of pts)
  • symptoms may persist even after med is stopped
57
Q

Tardive Dyskinesia - risk factors

A
  • elderly
  • female
  • DM
58
Q

Tardive Dyskinesia - treatment

A
  • clonazepam and gingko biloba

- Ingreza (valbenazine) or Austedo (deutetrabenazine)

59
Q

Neuroleptic Malignant Syndrome (NMS) - what is it?

A
  • life threatening medical emergency
  • associated with neuroleptic agents (ex: haldol)
  • usually occurs within first 2 weeks of tx
  • cause unknown, blocking of dopamine transmission
60
Q

Neuroleptic Malignant Syndrome (NMS) - criteria

A

Dx should be suspected with 2 of 4 features: mental status change, rigidity, FEVER, dysautonomia while taking a neuroleptic agent

61
Q

Neuroleptic Malignant Syndrome (NMS) - labs

A
  • elevated CK (shows muscle damage from rigidity) and elevated leukocytes
62
Q

Neuroleptic Malignant Syndrome (NMS) - management

A
  • STOP CAUSATIVE AGENT
  • supportive care - ABCs, etc.
  • lower fever, lower BP
  • prevent complications
  • *Dantrolene (direct-acting skeletal muscle relaxant)
  • recovery is 7-11 days
63
Q

Delirium - characteristics

A
  • acute disorder of attention with onset hours to days, characterized by confusion, disorientation, and fluctuation over the course of the day
  • # 1 cause = infection
  • factors that cause delirium include multiple meds, infection, metabolic disorders, electrolyte imbalances, dehydration, urinary retention, fecal impaction, > 60, frailty, visual impairment
64
Q

Delirium - exam

A
  • complete neuro (special attention to LOC, orientation, focal neuro defecits)
  • hearing and visual
  • pulm and cardiac exam
  • check for signs of infection
  • signs of trauma
  • MMSE and Geriatric Depression Scale
65
Q

Delirium - treatment (non-pharm)

A
  • supportive care
  • minimize stimuli
  • clocks and calendars
  • maintain hydration, nutrition, and oxygenation
  • bowel and bladder
  • keep on day/night schedule
  • TREAT UNDERLYING CAUSE
66
Q

Delirium - Management (pharm)

A
  • Haldol (QTc prolongation risk), Zyprexa, ativan IM
  • benzos (ativan) may worsen delirium/dementia (don’t use on elderly)
  • oral seroquel, zyprexia, risperidol may be used if patient is lucid
67
Q

PTSD - characteristics

A
  • complex somatic, affective, cognitive, and behavioral effects of psychosocial trauma
  • causes dysfunction of social, interpersonal, and occupations in one’s life
  • may feel depersonalized, may be unable to recall certain aspects of the trauma, often have flashbacks, dreams
68
Q

PTSD - criteria

A
  • must have had some type of exposure that led them to this issue, presence of intrusion of thoughts or symptoms, marked alterations in behavior, duration > 1 month
69
Q

PTSD - causes

A
  • sexual violence
  • interpersonal trauma (ex: loss of loved one)
  • interpersonal violence (ex: assault)
  • organized violence (ex: refugee)
  • combat
  • natural disasters
70
Q

PTSD - screening

A

20-point questionnaire

71
Q

PTSD - treatment

A
  • *SSRIs (first line), SNRIs
  • tx for 6 months but can be up to 1 year to prevent relapse/reoccurrence
  • refer if necessary
72
Q

Eating Disorders - avoidant/restrictive

A
  • cardinal feature is avoidance or restriction of food intake usually stemming from lack of interest or distaste of food
  • associated with weight loss, nutritional deficiency, dependency on nutritional supplements, marked impairment of psychosocial functioning
  • functional deficits and developmental delays may be significant if disorder is long-standing unrecognized
73
Q

Eating Disorders - anorexia nervosa

A
  • restrict caloric intake to a degree their body deviates significantly from age, gender, health, and developmental norms and exhibit fear of gaining weight and association disturbance of body image
  • can be very life-threatening
  • leukopenia, elevated BUN, metabolic alkosis, hypokalemia, hypothermia, sinus bradycarida, osteoporosis (huge long-term risk)
  • patient may report amenorrhea and skin abnormalities (petechiae, dryness)
74
Q

Eating Disorders - bulimia nervosa

A
  • engage in recurrent and frequent (at least once/month for 3 months) periods of binge eating and then resort to compensatory behaviors such as purging, enemas, laxatives, excessive exercise to avoid weight gain
  • fluid and electrolyte abnormalities, cardiac/conduction abnormalities
  • be alert for dental erosion and parotid gland enlargement
75
Q

Eating Disorders - when to hospitalize

A

KNOW THIS

  • hypokalemia or other serious electrolyte imbalances
  • syncope
  • hypoglycemic coma
  • symptomatic bradycardia
  • severe hypotension
  • dehydration
  • seizure
  • prolonged QTc
  • BMI < 14
  • development of suicidal r other psychiatric instability
76
Q

Eating Disorders - treatment

A
  • *cognitive behvaioral therapy

- antidepressants (SSRIs) for bulimia tx

77
Q

Decision Making Capacity/Capacity - characteristics

A
  • competent = only judge can decide
  • decision-making capacity = healthcare can decide
  • minimal mental, cognitive, behavioral ability, trait, or capability that is required for a person to perform a particular legally recognized act or assume legal role
78
Q

Decision Making Capacity/Capacity - most common reason to question decision making capaicty

A
  • when patient refuses tx

- our job is to explain tx, help them understand tx, alternatives, consequences, and ask why they are refusing

79
Q

Decision Making Capacity/Capacity - rules to exception

A

Medical emergencies
- lack of tx will cause permanent injury or death
- individual does not lack capacity to make the decision
- consent has been obtained from appropriate 3rd party
Incompetence (legally-deemed)
Waiver
Therapeutic privilege (disclosure of pt info would cause patient more harm or it is in the best interest of patient)

80
Q

Crisis Intervention - risk factors

A
  • illness
  • lost body part
  • lost role (ex: lost child)
  • threat of death
  • accident
  • financial or relationship issues
81
Q

Crisis Intervention - subjective findings

A
  • may be angry (esp. with healthcare personnel)
  • denial
  • depression
  • anxiety
  • slow thought processes
82
Q

Crisis Intervention - first step

A

KNOW THIS

- identify your own fears and concerns before you help anyone else with a crisis intervention and keep yourself safe

83
Q

Crisis Intervention - management

A
  • stabilize self
  • listen, encourage coping skills that have worked in the past
  • referral - social work, elicit social support
  • realistic plan

NUR: 718 (8 decks)

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